Prognostic factors of outcome in adults with non-traumatic altered mental status presenting to emergency department

Background: Altered mental status (AMS) is a common presentation in the emergency department (ED) and poses a significant challenge to the emergency physician (EP). The prognosis seems to depend upon many diverse factors, like etiology of AMS patient, clinical variables and various laboratory tests.Methods: The aim of the study was to determine outcome in patients presenting with new onset AMS to emergency department in our population. And further to look for various prognostic factors for death. Adult patients aged >14 years, not having dementia and with no history of trauma, presenting to ED with altered mental status were included in the study.Results: Out of 200 patients, 108 were male and 92 females. Patients having AMS because of poisoning, seizure, intracranial infection all had decreased mortality. Whereas patients having AMS because of stroke, infection, cardiovascular causes had significantly increased mortality. Season, sex, pH, SaO2, TLC, GCS, mean Bp. were associated with increased mortality in patients of AMS presenting to emergency department. The logistic regression model was statistically significant (chi square=39.3, p=0.000). The model predicted 26% of the variance in predicting death and correctly classified 74.6% of patients.Conclusions: The importance of being able to prognosticate AMS patients at outset in emergency is immense.Male sex, low mean BP, low GCS, low pH, low arterial SaO2, and high TLC were predictive of higher death rate in this cohort of patients presenting to emergency department

Alteración del estado de conciencia en el paciente intoxicado / Alterations in the state of consciousness in intoxicated patients / Alteração do estado de consciência no paciente intoxicado

La disminución del estado de conciencia, específicamente el coma, es un motivo de consulta frecuente en el servicio de urgencias y constituye un reto para el personal de salud por el número de condiciones amenazantes de la vida que se acompañan de este signo clínico. La toxicidad en el sistema nervioso central es una de las manifestaciones más comunes en el paciente intoxicado por cuanto se han encontrado signos y síntomas hasta en un 30%. Este porcentaje es considerable en personas en edad laboral pues la morbilidad derivada de un retraso en la atención y las lesiones secundarias, implican repercusiones sociales. Según su acción en el sistema nervioso central los xenobióticos se dividen en dos grupos: estimulantes que causan agitación, delirium o convulsiones y depresores que provocan grados variables de alteración en el estado de conciencia, desde la somnolencia hasta el coma. El propósito de este artículo es revisar las sustancias depresoras, con enfoque en el coma de origen tóxico. Además de la fisiopatología y los principales tóxicos implicados, se plantea, con base en la evidencia, la mejor aproximación a esta clase de pacientes con el objeto de favorecer el uso razonable de los recursos disponibles y evitar complicaciones y disminuir costos al sistema de salud.

Depression of consciousness ­ coma, specifically ­ is a frequent complaint in the emergency room consultation and is a challenge for health personnel, considering the number of life-threatening conditions that may be associated with this clinical sign. Toxicity in the central nervous system is one of the most common manifestations in the poisoned patient, where signs and symptoms have been found in up to 30%. This percentage is significant in working-age individuals as morbidity resulting from a delay in care and secondary lesions involves a social impact. According to their effect on the central nervous system, xenobiotics can be divided into two groups: stimulants that cause states of agitation, delirium or convulsions, and depressants that cause varying degrees of alteration in the state of consciousness, anywhere from drowsiness to coma. The purpose of this article was to review depressants, focusing on coma induced by intoxication. In addition to reviewing the pathophysiology and the main toxic substances involved, we consider the best approach to this class of patients based on the evidence, in order to favor the reasonable use of resources available, while avoiding complications and reducing health system costs.

A diminuição do estado de consciência, especificamente o coma, é um motivo de consulta frequente no serviço de urgências e constitui um desafio para o pessoal de saúde pelo número de condições ameaçantes da vida que se acompanham deste signo clínico. A toxicidade no sistema nervoso central é uma das manifestações mais comuns no paciente intoxicado pelo que se há encontrado signos e sintomas até num 30%. Esta porcentagem é considerável em pessoas em idade ativa pois a morbidez derivada de um retraso na atenção e as lesões secundárias, implicam repercussões sociais. Segundo sua ação no sistema nervoso central os xenobióticos se dividem em dois grupos: estimulantes que causam agitação, delirium ou convulsões e depressores que provocam graus variáveis de alteração no estado de consciência, desde a sonolência até o coma. O propósito deste artigo é revisar as substâncias depressoras, com enfoque no coma de origem tóxico. Ademais da fisiopatologia e os principais tóxicos implicados, se propõe, com base na evidência, a melhor aproximação a esta classe de pacientes com o objeto de favorecer o uso razoável dos recursos disponíveis e evitar complicações e diminuir custos ao sistema de saúde.

Can patients with non-convulsive seizure be identified in the emergency department? / 世界急诊医学杂志（英文）

@#BACKGROUND: Non-convulsive seizure (NCS) is an underdiagnosed, potentially treatable emergency with significant mortality and morbidity. The objective of this study is to examine the characteristics of patients with NCS presenting with altered mental status (AMS) and diagnosed with electroencephalography (EEG), to identify the factors that could increase the pre-test probability of NCS. METHODS: Retrospective study using the data collected prospectively. Inclusion criteria:patients older than 13 years with AMS. Exclusion criteria: (1) immediately correctable AMS (e.g., hypoglycemia, opiod overdose); (2) inability to undergo EEG; (3) hemodynamic instability. Outcomes compared between NCS and non-NCS cases: vital signs, lactate level, gender, witnessed seizure, use of anticonvulsive in the field or in the ED, history of seizure or stroke, head injury, abnormal neurological finding and new abnormal findings on head CT. Data presented as medians and quartiles for categorical and percentages with 95％CI for continuous variables. Univariate analyses were performed with Man-Whitney U and Fisher's Exact tests. A multivariate analysis model was used to test the predictive value of clinical variables in identifying NCS. RESULTS: From 332 patients (median age 66 years, quartiles 50–78), 16 were diagnosed with NCS (5％, 95％CI 3％–8％). Only age was significantly different between the NCS vs. non-NCS groups in both univariate (P=0.032) and multivariate analyses (P=0.016). CONCLUSION: Other than age, no other clinically useful variable could identify patients at high risk of NCS. ED physicians should have a high suspicion for NCS and should order EEG for these patients more liberally.

Urinary Tract Infection as a Cause of Hyperammonemic Encephalopathy / General Medicine

We report on a case of the altered mental status from hyperammonemia due to a urinary tract infection of urease-producing (urea-splitting) bacteria. A 98-year-old Japanese woman, who had no history of liver cirrhosis or portal hypertension, presented with altered mental status. The cause of the altered mental status was attributed to an elevation of ammonia in her blood. The urine culture grew Proteus vulgaris. Complete recovery occurred with the use of an antibiotic for the urinary tract infection. Among patients with urinary tract infections, but without liver cirrhosis or portal hypertension, production by urea-splitting bacteria and the subsequent tubular reabsorption of ammonia, may result in hyperammonemic encephalopathy.

Aspectos puntuales del estado vegetativo persistente / Specific aspects of the persistent vegetative state

El estado vegetativo persistente es una condición clínica caracterizada por la ausencia completa de conciencia sobre uno mismo y el entorno, unido a ciclos de sueño-vigilia, con preservación total o parcial de las funciones hipotalámicas y autonómicas del tallo encefálico. En el presente artículo, el autor discute aspectos puntuales sobre la entidad clínica, basado en su experiencia y en la revisión de la bibliografía sobre el tema; igualmente se exponen elementos clínicos y epidemiológicos de la afección, se propone una clasificación causal, y se enuncian los criterios de la Multisociety Task Force on Persistent Vegetative State para realizar el diagnóstico, así como los exámenes complementarios, que se dividen en estudios imagenológicos y electrofisiológicos. De los hallazgos anatomopatológicos se resaltan 3 patrones fundamentales: lesiones bilaterales y difusas de la corteza cerebral, daños difusos de las conexiones intra- y subcorticales de la sustancia blanca de los hemisferios cerebrales, y necrosis del tálamo; mientras que del tratamiento se proponen 2 pilares básicos: tratar la enfermedad de base y ofrecer cuidados generales. Entre los fármacos -- clasificados en 2 categorías: depresores y estimulantes del sistema nervioso -- se destaca el zolpidem, que ha mostrado los mejores resultados. Finalmente, se plantea que en Cuba se defiende que estos pacientes pueden ser asistidos en la atención primaria de salud.

The persistent vegetative state is a clinical condition characterized by the complete absence of consciousness of oneself and the environment, linked with sleep-wake cycles, with total or partial preservation of hypothalamic and autonomic functions of the brainstem. In this article the author discusses specific aspects related to the clinical entity, based on his experience and literature survey on the subject. Also, clinical and epidemiological elements of the condition are stated, a causal classification is proposed, and the criteria of the Multisociety Task Force on Persistent Vegetative State for diagnosis are set, as well as complementary tests, which are divided in imaging and electrophysiological studies. Of the pathological findings three fundamental patterns are stressed: diffuse bilateral lesions of the cerebral cortex, diffuse damages of white matter intracortical and subcortical connections of the cerebral hemispheres, and necrosis of the thalamus, whereas two basic treatment mainstays are proposed: to treat underlying condition and provide general care. Among the drugs --classified in 2 categories: depressants and stimulants of the nervous system-- zolpidem is highlighted, which has shown the best results. Finally, it is stated that in Cuba it is argued that these patients can be treated at the primary health care.

Evaluation and treatment of altered mental status patients in the emergency department / 中华急诊医学杂志

Objective To provide a framework for understanding the need for a structured assessment of altered mental status (AMS) to better understand underlying causes of the mental status changes in adults and therefore potentially improve diagnostic skills and eventually management.Methods This is a prospective cohort observational study.We recruited consecutive adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months.Demographical,clinical presentations,assessment approaches,cause factors,emergency treatments and outcomes were collected prospectively.Results One thousand nine hundred and thirty-four patients with AMS were recruited,this number of patients represented 5％ of the total ED census.Out of 1934 patients,1026 (53.1％) were male,908 (46.9％) were female.Mean age was (51.95 ± 15.71) years.Etiologic factors included neurological (n =641,35.0％),pharmacologic & toxicologic (n =421,23.0％),systemic and organic (n =266,14.5％),infectious (n =167; 9.1％),endocrine/metabolic (n =145,7.9％),psychiatric (n =71,3.9％),traumatic (n =38,2.1％),gynecologic and obstetric (n =35,1.9％).Total mortality rate was 8.1％ (n =156).The death rate was higher in elderly patients (≥ 60) than that in younger patients (10.8％ vs.6.9％,P =0.003).Conclusions The patient with AMS poses a challenge to physicians in ED.The most frequently encountered diagnostic category causing AMS were primary CNS disorders,intoxication,organ system dysfunction and endocrine/metabolic diseases.Fatality rate is very high.Prompt evaluation and treatment are essential to decrease the morbidity and mortality associated with this condition.

Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane / 世界急诊医学杂志（英文）

BACKGROUND: Altered mental status (AMS) is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of AMS patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management. METHODS: This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months (June 2009 to June 2011). Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected prospectively. RESULTS: In 1934 patients with AMS recruited, accounting for 0.93％ of all emergency department (ED) patients, 1026 (53.1％) were male, and 908 (46.9％) female. Their average age was 51.95±15.71 years. Etiologic factors were neurological (n=641; 35.0％), pharmacological and toxicological (n=421; 23.0％), systemic and organic (n=266; 14.5％), infectious (n=167; 9.1％), endocrine/metabolic (n=145; 7.9％), psychiatric (n=71; 3.9％), traumatic (n=38; 2.1％), and gynecologic and obstetric (n=35; 1.9％). Total mortality rate was 8.1％ (n=156). The death rate was higher in elderly patients (≥60) than in younger patients (10.8％ vs. 6.9％,P=0.003). CONCLUSIONS: Patients with AMS pose a challenge for ED physicians. The most frequently encountered diagnostic categories causing AMS were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. AMS has a high fatality rate in the ED. AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.

Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school / 世界急诊医学杂志（英文）

BACKGROUND: Alcohol-based hand sanitizers (ABHSs) have been widely used in homes, workplaces and schools to prevent the spread of infectious diseases. We report a young child unintentionally ingested ABHS at a school, resulting in intoxication. METHODS: The child was a 6-year-old girl who had been brought to the emergency department (ED) for hypothermia, altered mental status (AMS), periods of hypoventilation, hypothermia and vomiting. Computed tomography of her head revealed nothing abnormal in intracranial pathology. Urine drug screening was negative. Alcohol level was 205 mg/dL on admission. Other abnormal values included potassium of 2.8 mEq/L, osmolality of 340 mOsm/kg and no hypoglycemia. Further investigation revealed that the patient had gone frequently to the class restroom for ingestion of unknown quantities of ABHSs during the day. The patient was admitted for one day for intravenous fluid hydration and close observation of her mental status. RESULTS: The patient was discharged from the hospital the next day without any complications. CONCLUSION: Despite the large safety margin of ABHSs, emergency physicians need to be aware of the potential risk of ingestion of a large amount of such products in children and consider it in the assessment and management of school-age children with acute AMS.

Clinical Analysis on Patients with Altered Mental Status in the Emergency Department: Elderly versus Adult Patients

BACKGROUND: We compared elderly and adult patients and tried to find a way to make an early diagnosis and proper management for elderly patients with altered mental status in the emergency department(ED). METHODS: During one year, two groups -123 elderly patients over 65 years and 127 adult patients from 20 to 64 years who visited ED in National Police Hospital(NPH)-were selected. Sex, age, arrival time after symptom onset, means of transportation, underlying diseases, causative disease, time of notification to other departments, and pattern of discharge of two groups were analyzed. RESULTS: The average age of the elderly and the adults were 76.43+/-9.51 and 42.12+/-15.0(yrs), respectively. As for the means of transportation, 84% of the elderly used a 911 ambulance service, and 11% used other emergency services. The average times from symptom onset to arrival for two groups were 124 minutes and 69 minutes, respectively. 86.99% of the elderly and 68.38% of the adults had underlying diseases. As for final diagnosis, cerebrovascular disease for the elderly and cardiovascular disease for the adults were the main causes. When patients left the hospital, rate of transfer to other hospital was higher in the elderly(60.2%), and rate of discharge was higher in the adults(15.8%). CONCLUSION: The elderly patients had more intracranial causes and needed longer time for diagnosis than the adult patients. In the case of the patients with intracranial cause who needed an emergency care, they were usually diagnosed at the secondary medical facility and then transferred to the other hospitals for proper treatment causing bad effect on the prognosis of the treatment due to time delay.

Clinical Review of Elderly Patients Who Visited the Emergency Department with Altered Mental Status

PURPOSE: The number of geriatric patients admitted to the emergency department (ED) is growing as the elderly population grows. The altered mental status of the elderly is more difficult to evaluate and manage than others. The purpose of this study was to determine the etiologies of altered mental status in elderly patients visiting the ED. METHODS: A retrospective study was made of 119 patients who visited the ED of Kyungpook National University Hospital for altered mental status from January 2001 to June 2002. RESULTS: The results of this study showed that extracranial causes (67.8%) were more than intracranial causes (31.9%): metabolic (35.3%), cerebrovascular (29.4%), extracranial infection (16.0%), cardiovascular (8.4%), drugs/toxins (8.4%), and intracranial infection (2.5%). The group with underlying disease or with brain imaging done showed more intracranial causes than extracranial causes. The results showed that the age, the initial Glasgow coma scale (GCS) score, a new positive finding on a brain image, and the causes of the mental change had significant influence on improvement of the mental status and on the survival rate (p < 0.05). CONCLUSION: Initial evaluation of the underlying disease, the GCS score, an early study of brain imaging, and a search for possible metabolic causes, as well as others should be done simultaneously to deliver high quality care to elderly patient. Knowledge of the most frequent causes of altered mental status in elderly patients may assist the emergency physician in the approaching these potentially ill patients and managing their care.